Nurse Case Manager

11 hours ago

Pretoria, South Africa Recruitforce Group Full time

Position: Coordinator: Member Care (Pre-authorisations) Reporting to: Contact Centre Operational Manager Location: On-site at the Head Office, Pretoria _**You will be required to work shifts between 7h00 and 19h00 (Monday to Sunday)**_ **Qualifications**:

- Registered/ Enrolled Nurse
- Valid registration with SANC

**Skills and Competencies Required**:

- Minimum 2-3 years’ experience in a similar role within a managed healthcare or medical scheme environment
- Sound knowledge of the South African Healthcare industry and prevailing legislation, current coding structures i.e. ICD10’s, CPT4, NRPL, PMB conditions and clinical protocols
- Thorough, well-grounded clinical knowledge of the pre-authorisation of hospital admissions (including Length of Stay and Level of Care), in-rooms procedures and other healthcare services requiring pre-authorisation
- Excellent telephonic and written communication capability within a call centre environment _(will be tested) _
- Computer literate _(will be tested) _- MIP Application System experience will be advantageous
- Customer service orientation
- Ability to liaise with external parties - clinicians and members - and to make decisions
- Demonstrated ability to effectively deal with emotionally charged and stressful situations
- Self-motivator and the ability to work effectively in an independent environment
- Good organisational and task prioritisation skills
- Outstanding multitasking skills
- Proficiency in English - written and verbal _(an additional language will be advantageous) _
- Ability to research and analyse information
- High degree of accuracy and attention to detail
- Compile and submit relevant reports in accordance with strict deadlines
- Results orientated
- Maintaining confidentiality of information

**Summary of Responsibilities**:

- Attend to incoming calls from healthcare service providers and members/ beneficiaries
- Verification of the eligibility of cover within available benefits as per scheme rules, clinical protocols, and funding guidelines
- Strict adherence to benefits, scheme rules, clinical protocols and funding guidelines across all services and authorisation categories
- Clinical Risk Management to reduce the risks associated with hospital and other authorised services
- Establish the presence of any co-morbid conditions from the caller or beneficiary if caller is not able to assist
- Refer to member management if co-morbid conditions are present for intervention and follow-up
- Attend to general enquiries
- Prepare and present cases for escalation to member management for discussion and resolution
- Provide member care and education to patients with and without chronic conditions who need to participate in any of the registered active disease management programs.

**Job Type**: Permanent

License/Certification:

- SANC Registered (required)

Ability to Commute:

- Pretoria, Gauteng (required)

Ability to Relocate:

- Pretoria, Gauteng: Relocate before starting work (required)

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